Pilot Student Involvement Pilot Program (SIPP)

Glenwood Springs Fire Department

Pilot Student Involvement Pilot Program (SIPP)

About the Program

The Glenwood Springs Fire Department (GSFD) is taking applications for The Student Involvement Pilot Program (SIPP). Three Glenwood Springs High School students will be selected to participate in the pilot program with future goals to improve and expand. The SIPP will run June-August. Sippers who attend all assigned shifts and complete all assignments will receive a Certificate of Completion and receive 5 high school credits. During the program, students will learn basic firefighting and EMS skills and theories while they experience daily life as a firefighter and accompany firefighters on emergency calls as an observer.

The Application Process

Eligible applicants must be a current Glenwood High School junior or senior with reliable transportation to and from any fire station in Glenwood Springs. Applicants must submit a complete application prior to the deadline including, personal information, teacher sponsor, GPA report, essay assignments, signature, parental consent with notarized (third rider form).A current semester GPA of 3.0 or greater is required.

Applications will be reviewed by The SIPP Coordinator and Fire Officers. Top applicants will be interviewed by a GSFD panel for final selection. Selected SIPP participants (Sippers) will attend an informational meeting accompanied by their parent or guardian. The two-hour informational session will outline time commitments, uniforms, learning activities, tasks, and experiences that the Sipper can expect. The informational meeting will also cover safety procedures, emergency vehicle operations, and biohazard risk reduction. Thereafter, Sippers will attend pre-assigned shifts where they will explore the profession of a firefighter/EMT with a mentor.

Participant Expectations, Time Commitment, and Cost

Sippers will be expected to follow the rules and guidelines of the program at all times. Three assignments must be completed throughout The SIPP including journal entries, a final paper, and a final project (see attached for additional details on the assignments). Sipper will attend 2-3 shifts a month during the summer. Each shift will be a pre-assigned four-hour block.

Sippers mayhelp prepare and eata meal with their shift. The cost for the Sipper’s share of the meal will be five dollars per shift. Upon selection, Sippers will pay a $50 program fee to cover the cost of paperwork, protective gloves, eye protection, hearing protection, uniform T-shirt, and safety vest. Scholarships may be available to Sippers who cannot afford the program fee.

Contact SIPP Coordinator , Paramedic Travis Rohe, for additional information at .

Glenwood Springs Fire Department

Student InvolvementPilot Program Application

Please type in the fields or print using black ink.

1) Name ______Phone Number ______

Address ______Birth Date ______

Email Address ______

2) I have my parent’s permission to apply for the GSFD Student Involvement Pilot Program (SIPP)?

Yes No

3)Parent/Guardian Name ______Phone Number ______

Address ______

Parent email______

Emergency Contacts(2 Required)

4) Name ______Phone Number ______

Name ______Phone Number ______

Medical Information

5) Medical Conditions ______

Allergies ______

Do you need any special accommodations to participate in the SIPP due to medical status or disability?

Yes No

If yes, please explain______

Essay Questions

On a separate sheet of paper, provide answers to all of the following questions. Answers should be typed, grammatically correct, and free of errors. Answers to each question should be 300 words or less and should be single spaced.

1)Tell us about you. (Hobbies, interests, goals etc.)

2)Describe why you are interested in the Glenwood Springs Fire Department Student Involvement Pilot Program.

3)Without looking to outside sources, describe how you think The Glenwood Springs Fire Department serves the community and describe a firefighter’s daily routine.

4)How will this experience prepare you for life after high school?

______

Applicant Signature and Date

Teacher Sponsorship

Provide the signature of a teacher sponsor.

I think ______(applicant’s name) would benefit from the GSFD Student Involvement Pilot Program, would be a strong applicant, and take the experience seriously.

______

GSHS Teacher Sponsor Signature Date

______

Teacher Sponsor contact email

Proof of GPA

I have provided proof of a current high school grade point average of 3.0 or higher

Yes No

Attach to application

Parental Consent

My child, ______, has my permission to participate in the Glenwood Springs Student Involvement Pilot Program. I give my consent to allow______to be a participant in the activities outlined in the program and do not hold The Glenwood Springs Fire Department, it’s individual members, or The City of Glenwood Springs responsible for damages, injuries, or death associated with the participation in this educational experience. I understand that while my son/daughter participates in this program they may be subject to stressful or hazardous environments including but not limited to: hydraulic tool, sharp tool, and power tool (chainsaw) readiness checks, use of tools utilizing compressed air, climbing on vehicles at a height of greater than 10 feet without safety straps, the practice of using self contained breathing devices and firefighting protecting gear, observing the emergency medical care and aftermath of the sick and injured including the possibility of seeing violence, gore, blood, bodily fluids, and nudity, riding in vehicles while responding emergent (lights and sirens) to emergencies, possible exposure to structure/vehicle/wildland fire, heat, and smoke conditions from a distance deemed safe by GSFD staff, possible exposure to hazardous materials including biohazard, exposure to motor vehicle traffic, hiking to remote areas during a rescue, exposure to environmental heat and cold.

I also understand that I will need to attend a mandatory information meeting prior to my child’s participation in SIPP with an additional waiver and Contact of Understanding to be signed upon the meeting’s commencement.

______

Applicant Signature and Date Parent/Guardian Signature and Date

Additional forms include completed GSFD Third Rider Form

GLENWOOD SPRINGS FIRE DEPARTMENT

OBSERVER

RELEASE OF LIABILITY

I, ______, do hereby release the City of Glenwood Springs and all its officers and employees including members of the Glenwood Springs Fire Department from, and waive any and all liability, claims, demands for damages of whatsoever nature, including without limitation, claims arising from bodily injury, personal injury, property loss or damage, while riding as an Observer in a Glenwood Springs Fire Department emergency unit, or any liability as a result thereof during the date and hours approved herein by the Chief of the Glenwood Springs Fire Department.

Parent / Guardian (if under 18 years of age) Date

______

Observer Date Approved by Fire Chief: Date Observer Signature

SIPP Program Authorized to Ride: Summer 2014

This form must be notarized below

The foregoing was subscribed and sworn to before me this ______day of

______by______.

Observer (or Parent / Guardian if under 18 years of age)

Witness my hand and official seal.

My Commission expires: ______

______

Notary Public